Master thesis
“I am more than just a label”
An ethnographic study on pregnancy, morality and subjectivity in
Dutch women with a mental disorder.
Jantien Robertus
12184926
Master Medical Anthropology and Sociology
Graduate School of Social Sciences - University of Amsterdam Supervisor: dr. B.C. de Kok
Second reader: dr. E. Van der Sijpt Supervisor Erasmus MC: dr. H.H. Bijma
August 10, 2020 Amsterdam Word count: 21999
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Abstract
This study provides an ethnographic account of pregnancy experiences of women with a mental disorder. Drawing on semi-structured interviews with seven women, five key-informant interviews with caregivers, and an analysis of online data (forums, blogs, YouTube) and two autobiographical books, I examine moral discourses of motherhood and pregnancy that shape women’s subjectivities during pregnancy. I use Zigon’s anthropology of moralities and a Foucauldian approach to subjectivity to describe the tensions between moral ideals of motherhood and mental illness. I demonstrate how inability to live up to powerful discourses of ‘good’ motherhood and self-control can legitimize stigmatization and social exclusion of women with a mental disorder and how inability can structure their subjectivities in negative ways. At the same time, women enact agency by constructing counternarratives, but also by reproducing discourses of motherhood and pregnancy. A focus on women’s actions and decisions in pregnancy illuminates the way women with a mental disorder actively work on the self, and how they construct and present subjectivities. The study contributes to an understanding of how morality is embodied in subjectivities of mentally ill women, their everyday experiences of pregnancy and their actions and decisions. In doing so, the Western notion of self-control as an ‘empowering’ tool is being contested.
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Acknowledgements
This thesis is the result of eight months of hard work, and would not have been possible without the help of many people. First and foremost, I thank the women who participated for opening up about personal pregnancy experiences. I am grateful for your courage, generosity and openness.
I thank the professionals I spoke to for sharing their insights, showing their interest and giving their time in the midst of the chaos of Covid-19. I would particularly like to thank anthropologist/gynecologist Hilmar Bijma for this opportunity, recruiting participants, helping me clarify my ideas and sharing her anthropological and medical knowledge.
Thank you to the people who commented on versions of the thesis, or with whom I exchanged ideas in the course of this project; Riekje Elema, Lisa Lemmen, Hilde Robertus and Annekatrin Skeide. A special thanks to my supervisor Bregje de Kok for inspiring me, reading my work multiple times, providing critical feedback that helped me to sharpen my argumentation, but also for her kindness, encouragement and for checking up on me once in a while during the Covid-19 outbreak. Without her support, I would not have been able to do it.
Lastly, I thank my parents Hans Robertus and Anneke Kapenga for supporting me financially, but all the more emotionally, and enabling me to follow my dreams.
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4 Table of Contents
ABSTRACT 1
ACKNOWLEDGEMENTS 2
1. INTRODUCTION 5
2. EMPIRICAL AND THEORETICAL INSPIRATIONS 9
2.1IDEOLOGY AND DISCOURSE ... 9
2.2SUBJECTIVITY ... 10
2.3EXISTING MOTHERHOOD/PREGNANCY DISCOURSES ... 13
2.4MORALITY IN PREGNANCY DECISIONS AND ACTIONS ... 16
3. METHODS 19 3.1DATA COLLECTION ... 19
3.2REPRESENTATIVENESS OF SAMPLE ... 21
3.3IMPACT OF COVID-19 ... 22
3.4ETHICS ... 23
3.5LOCATING MYSELF IN THE FIELD ... 24
3.6DATA ANALYSIS ... 24
4. PREGNANCY WITH A MD: DOMINANT DISCOURSES 25 4.1DISCOURSE OF SELF-CONTROL ... 26
4.2DISCOURSE OF RISK: RISKY AND DANGEROUS MOTHERS. ... 30
4.3DISCOURSE OF MATERNAL HAPPINESS: ON A PINK CLOUD... 35
5. ‘MORAL’ ACTIONS AND DECISIONS IN PREGNANCY. 38 5.1TO BECOME OR NOT TO BECOME A MOTHER ... 38
5.2MOMS &MEDS:USE OF PSYCHOTROPIC MEDICINES ... 42
6. DISCUSSION AND CONCLUSION 50 6.1MAIN FINDINGS ... 50
6.2STUDY LIMITATIONS ... 54
6.3METHODOLOGICAL ISSUES AND IMPLICATIONS ... 56
6.4PRACTICAL IMPLICATIONS FOR HEALTHCARE POLICY AND PRACTICE ... 58
6.5REFLECTION OF THE RESEARCHER ... 60
6.6CONCLUSION ... 60
7. REFERENCES 61 8. APPENDIX 73 APPENDIX 1.DEFINITION OF MENTAL DISORDERS ACCORDING TO DSM-5. ... 73
APPENDIX 2.INTERVIEW TOPIC GUIDE... 75
APPENDIX 3.INFORMED CONSENT FORM... 78
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1. Introduction
Recently, perinatal mental health is considered a major global public health issue (American Public Health Association 2019; World Health Organization 2008: Rahman et al. 2013). A growing number of scientific studies have shown a link between perinatal mental health problems and poor perinatal outcomes: maternal mental health issues in mothers have been associated with maternal morbidity and (indirect) mortality (Austin & Highet 2011; Mordoch & Hall 2002), problems in the mother-infant relationship (Murray, Cooper & Hipwell 2003) and physical, cognitive-emotional and behavioral problems in the child (Satyanarayana, Lukose & Srinivasan 2011). In addition, medical professionals express concerns about the effects of prenatal exposure to prescribed psychotropic medication in pregnant women (e.g. decreased fetal growth, risk for malformations) (Creeley & Denton 2019). Literature indicates a lack of peer-reviewed studies on the use of psychotropic medication in pregnant women, as well as professionals’ need to ameliorate the quality and quantity of the available information regarding the safety of the use of psychotropic medication in pregnancy in order to better assist women in making informed decisions (Creeley & Denton 2019). Along with concerns about the effects of mental health and psychotropic medicines on perinatal health outcomes, current literature displays a negative view on motherhood by people with mental illnesses out of concerns regarding inadequate parenting style, emotional withdrawal, or irrational behavior (Oyserman et al. 2000). Consequently, scientific research linking mental health problems to fetal and childhood health risks mediates discourses that construct pregnant women with mental health problems – based on their psychiatric label – as ‘risky’ and ‘bad’ future mothers.
Anthropologists have unveiled the ways in which psychiatric labels, once established, tend to have an impact on those labelled (Laing 1964; White 2017). For example, as Halsa (2018) notes, social scientific literature has revealed that people with a mental illness are often perceived as deviant and are consequently socially excluded from society. Stigma attached to having a label of mental illness often increases in the case of becoming a parent (Wilson & Crowe 2009). Having a label of mental illness, which indicates deviance, has implications for the way pregnant women are treated by professionals. In the Netherlands
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and other Euro-American countries, a psychiatric label leads pregnant women to be singled out as ‘high risk’ pregnancies, pregnancies that require extra surveillance (Godderis 2010: Dolman, Jones & Howard 2013: Lupton 2012; Vervoort et al. 2016) and specialized care at a polyclinic for Pregnancy, Obstetrics and Psychiatry (POP-poli). Although pregnant women with a mental disorder (MD) are at the center of attention in terms of risk management, surveillance and medical interventions in Euro-American contexts, their subjective experiences remain largely understudied. This resonates what Oliver (2001) and Estroff (2004) describe; subjective experiences of those othered by difference are often undermined, by reason of an utterly ‘medical gaze’ (Foucault 1976/1963) that objectifies mentally ill patients, especially when they are construed as risk objects (Greenhalgh 2001). Most literature focuses on motherhood, and less on the lived experiences during pregnancy. This gap leads to a lack of understanding in professionals on how to best support women with a MD in pregnancy (Krumm & Becker 2006). To better understand the needs of pregnant women with a MD we thus have to move beyond a biomedical, ‘objective’, approach to the body, and examine ‘subjectivity’ (Montgomery 2005; Nicholson & Biebel, 2002; Seeman, 2004), which relates to a persons’ modes of perception, affect, thought, desire, fear etc. (Ortner 2005: 31).
Ethnographic studies on subjective experiences of motherhood in other ‘types’ of deviant mothers (e.g. substance using, teenage, or disabled women) clarified how dominant moral values and assumptions of ‘good’ motherhood and notions of deviance influence mothers’ subjectivities (Cense & Ganzevoort 2019; Wilson & Huntington 2005; Whitehead 2001; Halsa 2018). These studies illuminate how dominant motherhood discourses in Western society reflect neoliberal ideals of control, individual responsibility and self-discipline for management of risks in pregnancy (Frederick 2016). In chapter two I expand on dominant ideas of what constitutes ‘good’ motherhood. Qualitative studies on mentally ill mothers exhibit the way these neoliberal values put serious pressure on women, especially on those mothers considered ‘bad’ until proven otherwise (Halsa 2018; Montgomery et al. 2006). To sum up, existing literature shows how pregnant women are subjected to multiple discourses as well as to idealized standards of perceived good mothering, which pretend to hold the power to differentiate between ‘good’ and ‘bad’ motherhood. These moral discourses of motherhood and pregnancy presuppose and shape
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so called ‘moral selves’, i.e. subjectivities and the way one is perceived by others (Mahmood 2005; Arendell 2004; Hays 1996).
Anthropologists have scrutinized the interrelations between subjectivity and power for a long period of time. Subjectivity involves embodied, social and cultural processes through which the self is constituted (Venn 2006; Biehl, Good & Kleinman 2007). This process is largely shaped by cultural and social discourses. As many anthropologists have argued, people are not completely subjugated to these forms of power. For example, feminist anthropologists have illuminated the ways women enact agency by resisting dominant discourses (see e.g. Mahmood 2005/2006). Subjectivity is thus not a passive process, rather it is ‘work of the self on the self’ and thus about actions through which the moral self gets constituted, and is presented and expressed (Abenante & Cantini 2014; Venn 2006). In this thesis, I will expand existing anthropological work that examines how discourses direct people’s actions, how they shape their subjectivities and women’s agency to enact or resist dominant discourses (Abenante & Cantini 2014; Foucault 1995; Venn 2006; Wetherell 2008; Ortner 2005).
My analysis focuses on subjectivities in the period of pregnancy and during the transition to motherhood. The period of pregnancy is of special interest since it is a liminal period where a woman turns into a mother to be, and is subjected to motherhood as well as pregnancy discourses. It is my aim to develop an understanding of how moral discourses of pregnancy and motherhood shape subjectivities in Dutch women with a MD. When I talk about subjectivity, I refer to women’s subjective experience of the self and how others see them, and practical activities through which women engage identity (Biehl et al. 2007). Understanding how subjectivities are constructed and presented (by discourse and ‘work of the self on the self’) also requires an examination of women’s actions and decisions (Nichter 1998), since these (re)produce subjectivity. Though actions are integral to subjectivity, I separate actions and decisions for analytical purposes. Moreover, by taking into account work of feminist anthropologists (Holten 2013; Mahmood 2005), I examine how, if at all, pregnant women with a MD enact agency by reproducing or challenging dominant ideologies as reflected in different discourses. The sub questions that emerged are: How, if at all, do women construct and present moral subjectivities through their actions and decisions? And how, if at all, do women enact and challenge these discourses?
8 Thesis overview
In chapter two, I discuss theoretical and empirical literature on three key themes: discourse and ideology, subjectivity and morality. In chapter three I expand on the methodology, ethics, positionality and issues related to research during a pandemic (Covid-19).
In chapter four I begin my discursive analysis of the data: I use a Foucauldian lens to examine how moral discourses of self-control, risk and maternal happiness shape subjectivities in pregnant women with a MD. This leads to valuable insights into the ways women construct moral selves by reproducing or challenging dominant discourses.
In order to develop an understanding of the way actions (re)produce subjectivity, I discuss two important aspects in chapter five: psychotropic medication usage and becoming pregnant. These two actions, which emerged as important issues for women during interviews, shed light on how morality, subjectivity and discourse are entwined. I use an anthropology of moralities (Zigon 2008) to show the ways women actively work on the formation of the moral self, and face several ethical dilemmas within this process. In chapter six I summarize the main findings, answer the research questions and discuss limitations and methodological issues. I conclude with suggesting that future research and practice should continue to challenge the social (re)production of (unrealistic) moral discourses that contribute to the marginalized and disempowered position of women with a psychiatric label within the field of pregnancy and motherhood.
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2. Empirical and theoretical inspirations
Since subjectivity, discourse, ideology and morality are key themes in this thesis, I use this chapter to explore these notions, in combination with empirical and theoretical literature, in more depth before I present my analysis. I first discuss the concepts ideology and discourse. Thereafter, I examine the theoretical concept subjectivity and recent work on the anthropology of moralities.
2.1 Ideology and discourse
Purvis and Hunt (1993) note that the concepts discourse and ideology have been used interchangeably in social theory. Discourse analyst Van Dijk (2013) provides useful insights to compare and distinguish discourse and ideology in his work Discourse and Ideology. He argues ideologies are:
“Ideologies control and are formed by more specific socially shared attitudes about social issues that are relevant for the group and its reproduction. These attitudes in turn control the personal mental models [beliefs and perceptions about reality] group members form about specific events and actions, whereas these mental models again control actual social practices, such as the production and comprehension of discourse” (Van Dijk 2013: 194).
As I will show in this thesis, ideologies of motherhood involve shared values, beliefs, assumptions and expectations about what constitutes being a perceived good mother. Discourses are the social practices (text, talk and action), through which ideologies are “acquired, used, and spread” (2013: 176). Discourse is largely entwined with power, and involves ways of speaking, perceiving, and understanding governed by largely unconscious conventions and rules. In relation to subjectivity, Willig (2013:130) notes how “discourses offer subject positions, which, when taken up have implications for subjectivity and experience”. For example, risk discourses have become a dominant means of defining
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‘good’ and ‘bad’ mothers, hence pregnant women who drink alcohol (and put the fetus at risk) become highly stigmatized (Moore 2020). Accounts of pregnant women who feel ashamed and guilty about their alcohol consumption (Benoit et al. 2015) reflect how discourses shape subjectivities. Important to note: discourses do not merely shape what can be said and done in a field (e.g. medicine, femininity or motherhood), but also what cannot. In other words, women’s ways of acting and experiencing pregnancy and the self are highly influenced by social structures. Belek Ersen (2016: 375), in a qualitative interview study in Turkey, shows how the ideology surrounding love for your newborn shapes the language, and thus discourse, women use: “When I saw my baby I have a crash on her/him, there becomes an aureoia on my head, there was a sacred moment, that’s the moment I fell in love my baby”. Belek Ersen rightfully notes “No one talks about blood, tear, pain and puke”. His work clearly shows in which ways discourses reproduce knowledge about what is appropriate, and how these discourses (unconsciously) regulate women’s ways of speaking and thinking. Imagine the consequences of this normalizing discourse on the subjective experience of the self and the perceptions of others in women who lack this feeling of pleasure and love. Before we can explore how discourse and ideology shape subjective experiences, we first need to examine the concept of subjectivity.
2.2 Subjectivity
In ‘Subjectivities in dispute’ Estroff (2004) compares first person narratives of people with schizophrenia to second/third person narratives – dominant discourses produced by others in society. As she illustrates, dominant discourses reflected in scientific medical knowledge, cultural beliefs and public opinions are often “murky, incomplete, and in conflict about how much and what kind of agency and self-control to expect, demand, or recognize from the person with schizophrenia”(2004:300). Estroff shows how (ex-)patients with schizophrenia experience themselves as reduced to diseased brains and chemicals through the power and knowledge of professionals, whilst patients' subjective experiences remain marginalized and subjugated. Though Estroff focuses on the subjective element of subjectivity, rather than the social and political discourses that shape subjectivity, her work is useful in the sense that it underlines the importance of first-person narratives for policy and practice. As
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argued by Montgomery (2005), existing psychiatric and nursing literature on women with a MD has contributed to women’s ‘othered’ position, with largely focusing on their difference by illness and risks for poor perinatal outcomes (Godderis 2010: Halsa 2018: Dolman et al. 2013: Mordoch & Hall 2002). However, as mentioned, subjective experiences of pregnant women with a MD, and how these are formed by dominant discourses, remained understudied.
Many anthropologists have been concerned with understanding the subtle shaping of subjectivity (Whyte 2009). Subjectivity involves aspects of subjective experience and identity. Venn (2006) distinguishes ‘identity’ from ‘subjectivity’, though he acknowledges these are intertwined, suggesting that identity refers to categories related to social relations and connection to groups – such as parents or women. He describes subjectivity as the process through which the self is constituted. This process involves “an interiorization of attitudes, values, expectations, memories, dispositions, instantiated in intersubjective relations and activities that … constitute a particular named person” (Venn: 2006: 79). Wetherell, following Venn, argues that subjectivity is about “how a specific self lives those available cultural slots, actively realizes them, takes responsibility and owns them as an agent, turning social category memberships and social roles into ethical, emotional and narrated choices” (2008: 75).
As my analysis focuses on the formation of the self in pregnant women with a MD, as well as on their active or passive consenting, negotiating and resistant interactions with dominant discourses, I will first draw a picture of what lies beneath the idea of the construction of the self. From a Foucauldian perspective, cultural discourses and the medico-scientific gaze structure pregnant women as a ‘subject’. Foucault held the notion that subjects only come into existence through the complex interplay between power and language (1977/1995). As argued in the introduction of this thesis, subjectivity is not only passively shaped. Foucault’s (1988) “technologies of the self'' points to the ways people actively work on the formation of the self. These practices of the self reveal the ways in which dominant discourses may be “enacted, resisted, negotiated or differentially embodied in the individual’s ongoing ethical project of the self” (Johnson 2014: 332). This analytical framework enables me to identify the ways in which women with a MD constitute themselves as moral future mothers. For example, I highlight how women with a MD who take psychotropic medication, creatively enact discourses (“first care for the mother, than
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for the baby”) and resist others (“zero medication in pregnancy”) to form a moral framework that is satisfying to them, and allows them to become ethical subjects. Drawing on Foucault, Mansfield (2000) writes how in the formation of the self “we define ourselves according to authoritative notions of what it is to be well and not sick, sane and not mad, honest and not criminal, normal and not perverted.”
These notions (of being well/sick etc.) become particularly relevant for women when diagnosed with a MD and when falling pregnant. Weir (2006) describes that discursive constructions of risk in pregnancy can label women with a MD as “high risk”, and shape their subjectivities as well as the ways they are treated by healthcare professionals (which again affects women’s subjectivities). Godderis (2010), in her analysis of psychiatric research literature on risk discourses in the post-partum period in the US context, argues that the construction of postpartum depression activates risk discourses that position mothers as a risk to their children, and contribute to the construction of so-called ‘risky’ subjectivities. Godderis notes, supporting Foucault’s claim, that in the formation of the self women with a post-partum depression measure themselves against normative ideas of what constitutes a responsible and moral mother. Godderis and others also draw attention to the gendered dimension of risk and subjectivity since women appear to carry a moral responsibility for risk in pregnancy (Godderis 2010; Hallgrimsdottir & Benner 2014).
Many feminists employ Foucault’s work in their theories, but critiqued his work for its gender blindness. According to feminist scholars, subjectivity needs to account for gendered subjectivities and the ways in which social norms affect the subjective experience of the body (McLaren 2012: 81). Social scientists have highlighted the highly gendered ways in which pregnancy and parenthood get shape (Phoenix & Woollet 1991; Reed 2009; Godderis 2010). Social expectations and biomedical discourses on pregnancy often emphasize a woman’s responsibility, for instance in maintaining a healthy lifestyle during pregnancy (Markens, Browner & Press 1997; Reed 2009). Interestingly, though studies emphasize individual responsibility on the woman’s account, other studies on single-motherhood, where the woman naturally has individual responsibility, portray the absence of a male partner to share responsibility and resources with as problematic (Herbst-Debby 2018). This reveals the strong cultural belief in the ‘good mother’ as heterosexual and married (Godderis 2010). This heterosexual ideology also partly explains why lesbian women indicate resistance from their social network when becoming mothers
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(Hequembourg & Farrell 1999). These studies again point to the ways in which people perceive themselves and how others perceive them are highly influenced by (gendered) social inscriptions.
Whilst subjectivities in pregnant women with a MD have been neglected in social science literature, there is some literature on the post-partum period and motherhood (Montgomery 2005/2006; Dolman et al. 2013; Krumm & Becker 2006; Godderis 2010). Several scholars have shown how certain ideologies of motherhood can shape mentally ill women’s mothering experiences in negative ways. As mentioned, having a MD when pregnant can contribute to a discourse of risk, deviance or blame and shame which lead to a negative perception of the self (Moore 2020; Godderis 2010; Montgomery et al. 2006). At the same time, other studies pointed out the positive effects of mothering on mentally women’s subjectivities, suggesting a mother role can have a normalizing effect, lead to social inclusion, and contribute to a more positive perception of self (Krumm & Becker 2006). Since my aim is to examine the shaping of subjectivity, as functioning within a complex web of social relations, it makes sense to first examine the literature on dominant discourses of pregnancy and motherhood in high income settings, and show what deviating from these discourses does to (future) mothers’ subjectivities.
2.3 Existing motherhood/pregnancy discourses
Several motherhood discourses have been identified in high-income settings, which overlap/resemble each other. These include the discourse of ‘scientific motherhood’ (Apple 2006) which denotes the ways in which motherhood is perceived as an all-consuming project, demanding that mothers manage their children’s development in “partnership with medical and scientific experts” (Frederick 2016: 75). The scientific discourse (re)produces a biomedical understanding of motherhood and prizes normalcy. In addition, others have described a similar, yet different discourse on what they deem ‘intensive motherhood’ (Hays 1996). Similar to the scientific motherhood discourse, intensive motherhood is expert-guided and time consuming, yet the latter discourse is particularly “child-centered (needs of child before those of the mother), emotionally absorbing, labor-intensive, and financially expensive” (Hays 1996). Both discourses construct non-normative mothers,
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including women with a MD, as “’risky mothers’ who are inadequate for the task of ideal mothering” (Frederick 2016: 75).
The scientific knowledge that health of the fetus can be negatively affected by a woman's perinatal mental health, as argued in the introduction, creates a tendency towards a more controlling model of care (Coxon, Scamell & Alaszewski, 2012; Moore 2020). As a result, the feeling of ‘being watched’ creates high levels of stress in women (Montgomery 2005), which ironically can affect health of the mother and fetus negatively (Thomason et al. 2017). These studies elucidate how discourses offer ‘subject positions’ – (e.g. women with a MD as risky within risk discourse) – which has implications for subjectivity and pregnancy experience (e.g. high levels of stress).
Other studies also illuminate the ways in which medical knowledge and their discourses have the power to delineate ‘good’ and ‘bad’ motherhood, and inform ideologies but also everyday understandings of women themselves (Robinson & Richardson 1993). Frederick (2016) illustrates, based on qualitative interviews with deaf/disabled mothers in the US and Canada, how beliefs in the disabled women as abnormal and “an unwelcome drain on society” leads disabled women’s to be preoccupied with ensuring normalcy and controlling risk (Frederick 2016: 76): this demonstrates women’s ‘technologies of the self’ to construct and present themselves as moral mothers. Halsa’s (2018) study, drawing on interviews with mentally ill mothers in Norway, illuminates how deviance from intensive mothering discourses can lead to feelings of shortcoming, shame, guilt, worries about risks and a struggle for normality in women with a MD. These studies describe discourses about ‘ideal’ motherhood and their tendency to shape women as either ‘normal’ or ‘deviant’. Thereby these theories highlight to what degree deviance leads to a negative shaping of subjectivity and of the way one is perceived by others.
Scholars have identified the impact of negative perceptions of others on women’s sense of the self. Dolman, Jones and Howard (2013) based on a systematic review of qualitative literature and Lacey et al. (2015) drawing on surveys with mentally ill parents in Australia, argue that mothers with a MD often suffer from self-stigma, which means they come to see themselves as bad mothers based on deviance from the ideal of good motherhood. Where stigma is concerned with awareness of negative perceptions of others, self-stigma refers to an internalization of these negative perceptions (Watson et al. 2007),
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leading to devaluation and disempowerment (Corrigan & Watson 2002). These studies again show how motherhood discourses shape subjectivities.
Considering the relatively limited and only recent interest in maternal mental health (Satyanarayana et al. 2011), much can be learned from studies on pregnancy in teenage and disabled women, who like mothers with a MD, are often positioned at the bottom of the ‘social ladder of motherhood’. Neitermann (2012: 373) applies this term to refer to “an array of social perceptions that we have about ‘good’ and ‘bad’ mothers”. Cense and Ganzevoort (2019), in a qualitative study amongst Dutch teenage pregnant women, uncover how neoliberal discourses of self-control (Brown 2003), which imply individuals are “agents of their own success” constitute unintended teenage pregnancy as a result of “careless behavior” and thus as shameful (2019: 568). In Euro-American societies, where a capacity for self-control is a defining mark of personhood and moral worth, teenage girls and pregnant women with a history of drug-abuse and/or a MD are perceived as a threat to values of control, autonomy and responsibility (Gowan, Whetstone & Andic 2012; Halsa 2018).
A pregnant woman that is perceived as well-behaved and morally correct gets respected for her self-control and the restraint she exercises over her pregnant body to minimize possible risks (Lupton 1993). Scholars have argued an emphasis on women’s individual responsibility for pregnancy outcomes produces assumptions of control and choice (Ruhl 1999), while at the same time neglecting biological and socio-economic factors that are beyond one’s control (Lowe et al. 2015). As Montgomery et al. illustrate, based on qualitative interviews with twenty mentally ill mothers in Canada, many mothers with a MD experience their illness as ‘unpredictable’, ‘overpowering’ and ‘uncontrollable’ (2006: 23). Their findings show that a MD can interfere with neoliberal ideologies of self-control, and the way women draw on these discourses to construct and present a self and subjectivities. Some women tried to hide illness symptoms for their families to present a better version of the self – one that is in control and capable of dealing with mothering responsibilities (Montgomery et al. 2006).In feminist literature, much has been written on women needing to gain autonomy and power to decide on matters that affect their own bodies (Ginsburg & Rapp 1991), which coincides with the neoliberal ideal of self-control in Euro-American societies. In an essay on self-control in Western society, Joffe and Staerklé (2007) argue neoliberal ideals of self-control envision individuals or groups who lack self-control as “less
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valued and respected than those seen to embody self-control”. In my analysis of the interviews I will pay close attention to the strategies that both pregnant women and the medical personnel I interviewed mobilize in their applications and readings of these and other discourses. What I wish to highlight in this thesis is how discourses of self-control shape mentally ill women’s subjectivities, and may do more harm than good to the women in this study.
As noted by Mattingly, authoritative discourses provide guidelines for practice: a focus on actions and decisions thus provides a way to explore morality “not as abstract beliefs, codes or rules but as practices” (2013: 302). To gain a deeper understanding of how moral discourses shape subjectivities, it thus makes sense to examine how women with a MD present ‘moral’ subjectivities through actions and decisions. To successfully explore how moral discourses direct actions and decisions, and how these actions form part of the formation of the self, I draw on Zigon’s anthropology of moralities (2007/2008). Zigon’s work opens a new window on processes of ethical-self work, it allows me to see how women actively construct moral subjectivity through their actions in moments of ‘moral breakdown’. In addition, I focus how, within that process, women exhibit agency in the construction of the self by conforming to or by resisting moral discourses (Holten 2013).
2.4 Morality in pregnancy decisions and actions
Before I discuss how I will employ Zigon’s framework to clarify my analysis, I briefly introduce his theory.
Zigon distinguishes ‘the moral’ from ‘the ethical’. He defines ‘the moral’ as the unconscious everyday moral habitus informed by shared social norms in society. The ethical, in contrast, involves a breakdown in this unconscious everyday habituation of moral norms and values; it presents a person in a situation where one has to “stop and consciously consider how to act in a morally appropriate way” (Zigon 2009: 260).According to Zigon, the unreflective, unconscious nature of morality in everyday life makes it complicated for anthropologists to bring morality into full view. What Zigon’s framework adds to other scholarly work on ethics, is his focus on a particular event or episode in which taken-for-granted morality is disrupted. To better capture moral experience, Zigon advocates an
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anthropology of moralities that focuses on ethics as performed in moments of ‘moral breakdown’ - a moment typified by a person feeling confronted with the necessity to determine which norm will direct action in the most appropriate and satisfactory way (Zigon 2009; Robbins 2009). During a moral breakdown, people are thus asked to step away from unreflective everydayness, and reflect on the right ethical response (Holten 2013:72).
Since the pregnant women with a MD I interviewed situate themselves in a liminal state in which they turn into a mother, their taken-for-granted everyday morality appears disrupted; within the (re)formation of the self as a moral mother to be, women face ethical dilemmas in regards to having a MD and have to carefully negotiate new norms attached to this social role in order to construct and present a moral self. In this respect, I argue that particular actions and decisions in pregnancy with a MD can be seen as a ‘moral breakdown’ (Zigon 2008: 165 as cited in Holten 2013). I employ Zigon’s work to examine two moments of moral breakdown articulated by women I interviewed, which forced them to reflect on how to act morally appropriate and present a moral self: the decision and action to use or refuse psychotropic medication and to become a mother (or not) while having a MD.
Actions and decisions appear a way for pregnant women to prove moral worth as a mother to others and themselves (Savvidou et al. 2003). As shown in the literature, other ‘types’ of deviant mothers often feel the pressure to prove their moral worth, and thus consciously reflect on how to behave morally appropriately. An analysis of these accounts of moral breakdowns reflect the ways in which women actively work on the self and the way others perceive them by enacting, resisting and negotiating moral discourses. For example, I show how women reflect and decide on the right ethical response regarding whether to cease or continue taking psychotropic medication, balancing the risks to the fetus, her own mental wellbeing, but also the risk of being socially labelled a bad mom (because medication-use in pregnancy is often disapproved within discourse).
Within discourse people have agency: the power to implement established discourses on people has its limits and therefore moral inscriptions (e.g. no alcohol in pregnancy) cannot be made completely obligatory (Zigon 2009). Halsa (2018) highlighted how mentally ill mothers find alternative ways to fulfil the moral obligations of ‘intensive mothering’ (e.g. by receiving additional support of family or neighbors), which allows these women to construct a positive self/subjectivity and manage the image of a ‘good’ mother towards others (Halsa 2018). For example, I show how for some women the consequences
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of quitting medication are more detrimental for the fetus’ health than continuing (e.g .because it leads to mental overwhelm and inability to care for self/fetus). For these women, continuing their medication may be the right ethical response to ‘protect’ the fetus. In that sense, they fulfill the moral obligations of protecting the fetus in an alternative way. Inspired by Mahmood’s evaluation of women’s agency in inhabiting the Islamic religious discourse (2005), I analyze the agentic ways in which resist or comply with the norms to construct a moral self. At the same time, I examine situations in which their agency might be constrained, and I illuminate hegemonic discourses marked by the idea that individuals are able to control their own bodies and life. In chapter six discussion, I will illustrate how my findings add to notions of ‘social navigation’ (Vigh 2006) or ‘reproductive navigation’ (Van der Sijpt 2014a). I demonstrate, as the concept of navigation implies, that women's actions and decisions highlight the complex interplay between individual actions and structural factors (moral discourses) (Van der Sijpt 2014a; Vigh 2006/2009).
The presented literature digs into the need to look at the links between discourse, morality, agency and subjectivity. Having sketched the literature and theory, I now turn to the ethnographic material to investigate in which ways women’s experiences constitute these links. In order to get to an analysis of how moral discourses shape women’s subjectivities, it is important to first analyze the dominant discourse in the field. These, and how these discourses shape subjectivities in pregnant women are the focus of chapter four. In chapter five, I will analyze women’s actions and decisions to understand how these are entwined with moral discourse and constitute subjectivity. Before I turn to an analysis of the data, I discuss the research methods.
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3. Methods
This thesis is based on an ethnographic study conducted between February and April 2020, during the worldwide Covid-19 outbreak. In what follows I will describe methods of data collection, obstacles I encountered (related to Covid-19 and other issues) and how I dealt with these.
3.1 Data collection
During ten weeks, I conducted ethnographic research in the Netherlands to explore mentally ill women’s pregnancy experiences. I started with six key-informant interviews to obtain background information about the research topic. I interviewed a gynecologist, a nurse practitioner and a midwife working in Pregnancy, Obstetrics and Psychiatry care in two different hospitals; a social worker from an social organization for (future) mothers facing psychosociological problems; and a sex-therapist and nurse who provided contraception and pregnancy counselling to women with a MD. The interviews enabled me first of all to identify dominant frameworks of discourse in the medical practice. Besides this I explored the professionals’ perspectives on pregnancy in women with a MD in combination with an investigation of medication use, the obstacles encountered by women and professionals and how care is organized. Furthermore, I attended three research meetings at the department of Obstetrics and Gynecology at the Erasmus MC. Listening to discussions of medical researchers provided insight in the medical language used, the production of medical knowledge about ‘good’ or ‘risky’ pregnancies and issues related to moral appropriate behavior.
In addition, I conducted seven in-depth, semi-structured interviews with women with a MD about their pregnancy experiences. Table 1. presents an overview of the participants. Although the focus in this thesis is on pregnancy experiences, I also included one postpartum woman in the sample. Interviewing her enabled me to include experiences of a woman who was according to herself too unstable to participate (in research) at the time of pregnancy. Women had different socio-economic backgrounds, and lived in urban, as well as in rural areas around the cities of Rotterdam and Groningen, the Netherlands. Six
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women called their pregnancies to a certain extent planned (I will turn to this notion of planning and control in chapter 4). One pregnancy was unplanned. This woman was also the only participant without a partner. Nevertheless, she still wanted the baby.
During one interview it seemed that a woman was performing or convincing me of her ability to mother. I noticed an aggressive tone in her answer on my question on how she dealt with particular risks during pregnancy. After I asked her if and why my question frustrated her, and apologizing, she explained that she felt like she always had to prove that she was “doing pregnancy the right way” under the watchful eye of so many professionals. As Glaser (2001) said “all is data”. The finding that this woman felt the pressure to prove her moral worth as a pregnant woman to me as a researcher provides insight in the social pressure women experience to meet expectations and ideals of motherhood and pregnancy. And more importantly, the notion that mothers with a MD are per definition perceived as bad mothers, until proven otherwise (Savvidou et al. 2003). In hindsight, I realize how my research activities may have pushed women to a certain subject position, evoking the need to prove themselves as moral mothers. I expand on this in the discussion.
Table 1. Overview Participants Women Pseudonym Age Number of
pregnancies
Weeks pregnant
MD Diagnosis
(See Appendix 1 for definition according to DSM-5) Partner Education (Dutch system) Anna 34 Second - daughter of three years 24 Schizoaffective disorder
Yes Bachelor’s (hbo)
Nienke 40 First 27 Post-traumatic
stress disorder
No High school
Nicole 36 First 38 Bipolar disorder Yes Master’s
Nina 32 First 32 Depressive
disorder
Yes Master’s
Sasha 29 First 15 Depressive
disorder Yes Undergraduate Jasmin 28 First 10 months postpartu m Generalized anxiety disorder with depression
Yes Bachelor’s (hbo)
Tessa 29 First 25 Anxiety disorder
with depression
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In addition to interviews, I conducted online ethnographic research. I analyzed Dutch blogs, forums and YouTube videos on experiences of pregnancy with a MD. Since online-interactions are a large part of our Western everyday lives, they produce rich data on thoughts, ideas and narratives (Kurtz et al. 2017). Online ethnography enabled me to do non-participant observation without participants awareness of being observed (Lamerichs & te Molder 2003); provided insights in new ways of performing identity online (Iphofen 2013); and discourse analysis of forum talk helped me to understand women’s shared experiences of illness in online spaces where the healthcare system has a less dominant position (Smithson 2015). Despite many advantages, online ethnography also poses challenges. For example, lack of knowledge about demographics; lack of non-verbal communication; problems with authenticity (think of scripts for YouTube videos) and issues of privacy (e.g. public or private domain) (Iphofen 2013; Kozinets 2010), I expand on this in the ethics section of this chapter.
In addition to online research, I examined two Dutch autobiographical books1 on pregnancy with a MD. Autobiographical accounts produce valuable data to understand lived experiences from the author’s perspective, concentrating on what the author considers important and meaningful (Power et al. 2017; Sommer, Clifford, & Norcross, 1998)
3.2 Representativeness of sample
This study involves a small sample of seven women, and the fact that almost all pregnancies were described as wanted and planned means that the participating women’s accounts may not be representative of women with MD ‘in general’. It is possible that women with an unplanned and more particularly, unwanted pregnancy are less likely to participate and find it more difficult to talk about their pregnancy experiences. Moreover, all women received professional care during pregnancy. Those who do not seek care or prefer to hide their history of mental health problems are probably less willingly to participate. Two invited women – one recruited by me and the other by the gynecologists – refused to participate
1
Van Zelm, V. (2018). Feliciteer hem maar want ik vind er tot nu toe geen reet aan. Alkmaar: Pepperbooks
Kalsbeek, A. & Stevens, A. (2017). Het kan echt iedereen overkomen. Zoetermeer: Uitgeverij Lecturicum.
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because their mental health problems in combination with pregnancy experiences were too emotional or traumatic to talk about. It is thus possible that women who participate cope relatively well with their situation and find it less difficult to talk about these topics compared to those not willing to participate. Lastly, most participants completed an education which is not representative for the general population. This is partly because I recruited via my own ‘middle-class’ social network.
3.3 Impact of Covid-19
Initially, I conducted research in collaboration with a gynecologist at the Erasmus MC, but due to Covid-19 all patient-oriented research was put. At that time, the gynecologist recruited four women. Recruiting participants myself posed several challenges, but also turned out to have positive outcomes. A challenge of recruitment through friends and family was the taboo and stigma that appears to exist on the topic of mental health, in particular in relation to pregnancy. A few people knew someone who experienced mental health problems during pregnancy, but told me how this remained some sort of taboo within families or groups of friends, which created barriers for recruitment.
An advantage of recruitment independent of the Erasmus MC is that it enabled me to include participants from different geographical areas in the Netherlands. Women living in rural villages in the north of the country seemed to experience, or at least expressed, higher levels of taboo and (fear of) stigma, an insight I would not have gotten otherwise. After posting a research flyer on social media, LinkedIn and contacting seven midwife practices, I managed to find three other participants through a midwife practice in Groningen.
In compliance with the Covid-19 rules of the Dutch Government (i.e. stay at home), I conducted six interviews on Zoom and seven by phone. The use of technology created methodological opportunities in times of social distancing. Three women indicated participating in research is easier over phone/Zoom as no effort is required to meet in person and phone interviews felt more anonymous for them. One woman compared the phone interview with a “confessional” where one could speak openly and anonymously about personal experiences. Another advantage of video calling, as identified by Lo Iacono,
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Symonds & Brown (2016), is that it allows data collection over larger geographical areas. I was hesitant whether to continue interviews during a worldwide pandemic – as I did not want to burden women. However, for women it also seemed a way to share their experiences of pregnancy during a stressful, and sometimes very isolated time. I expand on the methodological issues in regards to remote interviews (e.g. lack of non-verbal communication) and lessons taken from this innovative way of interviewing in chapter six Discussion.
3.4 Ethics
During fieldwork and thesis writing I paid careful attention to ethical considerations. I obtained verbal and written informed consent for participation. I used pseudonyms instead of real names. Before each interview, I called with each woman to introduce myself and to explain the aim of the interviews. I emphasized my aim was not to explore their mental health problems, but to gain insight in pregnancy experiences (regardless of whether mental problems were an issue). I emphasized women could skip questions and discontinue interviews at any given moment. Moreover, I offered a follow-up two days after participation, five women said this was not necessary. Many women had years of experience talking about their issues as patients, came across steady and stood up for themselves. I then realized women may experience a researchers’ follow-up call as belittling, and reinforces their ‘vulnerable’ and ‘unstable’ status.
In addition, as mentioned, online ethnography posed challenges related to privacy. Since I could access online sources without registering or being approved to the ‘online community’ (Hine 2000), these can be considered public domain and analyzed without consent (Whiteman 2012). I draw on Whiteman’s (2012: 12) argument that obtaining consent in online forums can be disruptive. Nevertheless, I took several precautions to prevent doing harm and maintain anonymity and confidentiality of online community members. All forum-users appeared to use pseudonyms instead of their real names, but I have chosen to treat these with the same respect as I would treat a person’s real names. To avoid the possibility that persons can be traced back, I do not mention names of online data sources (British Psychological Society 2017; Koning et al. 2019).
24 3.5 Locating myself in the field
To be able to properly interpret the research data, I have to reflect on my own subjectivity. My mental health nursing experience and skills, i.e. quality interviewing, listening and careful observations and interpretations (Borbasi et al. 2003), enabled me to gain rich data and to deal with the sometimes difficult and emotional laden conversations. However, being a mental health nurse also led to blind spots. I may have taken for granted what mental disorders involve based on my former nursing training and work, while neglecting the social meaning women attribute to it. It helped me to behave like I had limited knowledge about mental disorders as well as pregnancy, which is true, as it helped to invite women to share their own perspectives. My bias about categorizing people by diagnosis in nursing was diminished by my decision not to ask actively about their mental illness symptoms, unless it explicitly came up in interviews (See Appendix 2. Topic Guide). Hopefully, in that way I allowed women to freely present their subjectivities during interviews, avoiding the pitfalls of categorizing them based on my interview questions. Since I conducted research as a medical anthropologist, not a nurse, I considered it ethically justifiable to not inform women about my nursing background unless it explicitly came up in a conversation.
3.6 Data analysis
I used the principles of a grounded theory approach (Glaser & Strauss 1967) to try to understand the social processes that shape women’s pregnancy experiences. The data was coded and analyzed in MAXQDA. First, I analyzed the data using open, descriptive coding to identify recurring themes. Next, I conducted focused coding based on the topics that emerged from the first round of coding. In the preliminary data analysis, women’s continuous considerations on behaving in a morally appropriate manner emerged as a recurring theme. As I gained new insights during the fieldwork period, my initial theoretical framework did not fully cover what was important and emergent for women. Nevertheless, as Charmaz notes, initial theoretical concepts created useful points of departure for “developing, rather than limiting, our (my) ideas” (2006: 17). Based on new insights from
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the data, I needed new theoretical concepts to explain them. Foucault’s theory on subjectivity was a useful methodological tool for studying how moral discourses of pregnancy shape women’s subjectivities. Zigon’s framework was particularly helpful to clarify my analysis of particular situations marked by ethical dilemmas and how women determine the right course of action that allows for the construction of a moral self.
I draw on principles of Foucault’s discourse analysis to analyze women’s and professionals accounts. For Foucault, discourse analysis involves identifying ‘discursive formations’, the practices of discourse, and social power relationships expressed through language and practices. According to Foucault, we speak of discursive formations when we identify a regular, systematic dispersion of the representation of the knowledge about objects, the meanings of statements within social life and institutions (Foucault, 1972: 38). Foucault’s discourse analysis enables me to move away from content and surface descriptions (e.g. as done in thematic analysis), it provides an analytical and theoretical lens to interpret data in relation to its social context. In my analysis of narratives I look at performative, as well as content aspects; I approach interview talk as a form of social action in itself, a way to present the self in a morally decent light (Goffman 1959). Drawing on Foucault, I will analyze the ways in which the discursive formations attached to ideals of motherhood “govern what can be said, thought and done within a field” (Luke 2001: 2), but also look at women’s agency to resist discourses.
4. Pregnancy with a MD: dominant discourses
In this chapter, I will analyze three dominant discourses, or discursive formations2 of motherhood and pregnancy as I observed them in my data. In addition I will analyze how women respond in regard to: the discourse of self-control; the discourse of risk in relation to mental illness; and the discourse of maternal happiness. The discourse of self-control is intertwined with the other two discourses, and appears as a central thread throughout this thesis – shaping women’s subjectivities and actions in several ways.
2
26 4.1 Discourse of self-control
As mentioned, in the Dutch context in which this research took place, as in other Euro-American settings, people are preoccupied with an idealized notion of individual responsibility and control over one’s life (Joffe & Staerklé 2007). A capacity for self-control contributes to women’s overall moral status (Gowan et al. 2012). This applies also and perhaps even more so to pregnant women and early motherhood. In this paragraph I highlight the ways ideals about self-control, which include notions of individual responsibility and choice, are reproduced and challenged by women and medical personnel I interviewed.
When talking about self-control in pregnancy, we should also include the (in)ability to control whether one gets pregnant at all. Both the sexologist and social worker noted that women’s ability to control falling pregnant and pregnancy in itself can be hindered by lack of knowledge, financial resources, the body itself or the presence illness symptoms. Anna’s narrative about being actively suicidal when she fell pregnant for the first time illustrates how illness symptoms can lead to loss of control:
“I was mentally very unstable at that time. I was…I was planning my suicide to be very honest...I thought it was the easiest way back then. And suddenly I got pregnant! [voice lifted] And then I thought: WHAT?! I’m really pregnant. And then it…it literally came a week before the moment I had planned to do it [commit suicide]. Yeah that was really special. And that [the pregnancy] was actually a moment that everything started to turn around for me.3” (Anna, 34, schizoaffective disorder, second pregnancy)
Anna demonstrates not only how mental health issues can lead to a loss-of-control over falling pregnant, but also that, beside limits of control due to psychological factors, the body itself also has “a will of its own” (Van der Sijpt 2014: 65). In other words, the body
3
Original quote: “Ik was toen mentaal heel onstabiel ook. Ik was…ik zat mijn zelfmoord te plannen om heel eerlijk te zijn … ik vond dat de meest makkelijke manier destijds. Maar toen werd ik zwanger opeens! [klinkt opgeheven] En toen dacht ik: WAT?! Ik ben gewoon zwanger. En toen is het…het kwam echt letterlijk een week voordat ik het [zelfmoord] gepland had. Ja dat was wel bijzonder. En eigenlijk was dat [de zwangerschap] een moment dat voor mij alles om ging draaien.”
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itself can hinder women’s agency in determining the course of pregnancy. Many other women I spoke with expressed the unpredictability of the fertile body in a similar fashion, accentuating the inability to plan pregnancy – either they had to wait for a long time or fell pregnant “too fast”. What comes across strongly in Anna’s account is a counternarrative that constructs lack of control over the reproductive body as a ‘blessing’, at least in Anna’s case it literally saved her life.
Despite women’s (and healthcare professionals’) emphasis on limits of control in pregnancy and falling pregnant, their accounts show continuous efforts to (re)gain control over the process. During interviews, professionals and pregnant women talked about birth plans, parenting plans, pregnancy schedules, apps to monitor the course of pregnancy etc. All activities indicate a demand for control, or what Bushnell describes as “modes of creating an illusion of control” (2020). To engage in activities to ‘control’ pregnancy appears a way for women to perform moral identity to themselves and others.
Anna also engaged in several activities of self-control to perform her moral identity as a pregnant woman and mother. She spoke about making a parenting-, birth-, and relapse prevention plan – with the intention to control these events. Her account reveals how medical practices (e.g. birth plans) (re)produce an illusion of control, but also how a paucity of self-control triggers an idea of immorality. Anna notes:
“I am not the mother I had planned to become…I thought I would be a very social, active mother, I thought I could go out a lot with my daughter. I puzzle with her at times and these kinds of things. But I perceived myself to be a completely different type of mother. And at times I’m really, really tired…I wish I had more control over it. But I am anyway, I don’t have a lot of control over my body anyway because of my psychological problems. Yes I just say that honestly.4” (Anna, 34, schizoaffective disorder, second pregnancy)
Earlier in the interview, Anna indicated “I am not convinced I am a good mother”. Anna’s construction of the self as not an ideal mother, is interlaced with her deviance from
4
Original quote: “Ik ben niet de moeder die ik ooit gepland had om te zijn … Ik dacht dat ik een hele sociale, actieve moeder zou zijn, met mijn dochter veel naar buiten zou kunnen gaan. Ik ben wel bezig met haar af en toe met puzzelen en dat soort dingen. Maar ik had mezelf als een hele andere moeder voorgesteld. En ik ben soms ook heel erg moe … Ik wou dat ik meer controle daarover had. Maar ik ben sowieso. Ik heb sowieso niet zoveel controle over mijn lichaam door mijn psychische problemen. Ja dat zeg ik gewoon heel eerlijk.”
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the discourse of intensive mothering (Hays 1996) (active, energetic, social mother), but aggravated perhaps by the fact that she tried but failed to control her motherhood. The above narrative shows a lack of ability to control how we mother – especially when having a mental illness. Her statement “Yes I just say that honestly” can be seen as reflecting that lack of control is a touchy sensitive topic. The inability to govern and control oneself in the performance of motherhood/pregnancy is seen as a moral failure on its own, but all the more if this is regarded as putting one’s fetus or child at risk. As for Anna, her inability to control expectations of good motherhood shaped her subjectivity in negative ways: she reports feelings of disappointment, failure and low self-esteem. Above narrative is an example of how facing mental health problems means that mothers have to renegotiate their socially structured dreams, desires and expectations.
Not only Anna related to the moral aspect of the control discourse. The view of control over the pregnant body as a form of morality could also be noted by medical experts’ preoccupation with controlling risk and individual responsibility. Health professionals encouraged women to engage in self-discipline to increase and maintain the wellbeing of the fetus and self (e.g. quit alcohol and smoking, eat healthy, lower stress). Jasmin’s narrative reveals a high awareness of medical knowledge about the impact of her behavior on the fetus’ development, and the need to control certain risks, but also shows how the interiorization of medical discourses can inform pregnant women’s modes of thought, fear and stress:
“…and then you think ‘oh no I shouldn’t worry’ because stress is even worse for your pregnancy!! So I’m NOT allowed to do that’…and yeah then it only gets worse…[laughing]5” (Jasmin, 28, first pregnancy, generalized anxiety disorder)
When Jasmin talks about stress, she draws on a biomedical discourse which allows her to construct stress as risky and to attribute personal responsibility of posing the fetus under risk. Her statement “So I’m NOT allowed to do that” can be seen as reflecting that stress is something to control too. Ironically, as Jasmin shows, feelings of responsibility and
5
Original quote: “… en dan denk je ‘oh nee ik mag niet piekeren’ want stress is nóg slechter voor de zwangerschap!! Dus dat mag ik NIET doen’.. en nou ja dan wordt het alleen maar erger…[lacht]”
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concerns about the impact of stress on her fetus seem to lead to more stress; again drawing attention to the impossibility of control.
Women also reflected a discourse of control in narratives about how to deal with future challenges in mothering with a MD. The conviction that others would judge them as ‘lacking control’ and failing mothering seemed to result in women’s ‘over conscious mothering’ (Malacrida 2009) and efforts to reveal their level of control to others. For example, women spoke about how they would deal with possible future recurrence of worsening of illness symptoms – when having to care for a child. How to deal with lack of sleep as a newborn mother, bearing in mind that lack of sleep is a trigger for worsening of illness symptoms. To justify to others the way they would ‘control’ future challenges seems even more important for women with a MD – because it is a way to prove their moral worth.
While medical practitioner’s accounts largely reproduced gendered responsibility discourses (Godderis 2010), in the ways they encourage the mother to change her behavior, several women actively resisted notions of individual responsibility. As for Anna, the role of her partner, a shared responsibility, was crucial. She told me how he signaled a worsening of her illness symptoms and protected her by decreasing stimuli and by talking to professionals. In these ways, they shared the responsibility of protecting the fetus. Anna’s account portrays an interesting counternarrative that challenges dominant discourses which construct the mother as the sole responsible agent (Godderis 2010). Other women also indicated the importance of ‘doing it together’. For them, partner support was a necessary condition before falling pregnant. The thought of ‘doing it together’ was often reassuring and increased women’s trust in the capability to deal with motherhood.
Interestingly, despite the dominant individual gendered responsibility discourse in pregnancy, the only participating single woman experienced stigma related to raising a child without a (male) partner. Historically, lack of shared responsibility in single-motherhood is represented as a risk to a child’s well-being (Coe 2011). It appears that having a partner is something women are supposed to control as well and are being held responsible for. When mentally ill, the role of the partner as a safeguard and backup (i.e. shared responsibility) seems to be even more crucial – as reflected in accounts of professionals, women themselves and in social reactions of others. Partners’ support can be seen as an alternative
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way to fulfil the moral obligations of motherhood, even if you are unable to live up to dominant values of motherhood (i.e. intensive motherhood) and individual control.
The inability to live up to the values of autonomy and self-management can disempower women, as can be seen in several accounts of women I talked to. This appears to be the case in particular because the ideology of self-control portrays women unable to pursue these values as failing at ideal mothering. Women’s accounts suggested that failure to attain the ideal of self-governance creates feelings of guilt and shame and can lead to lower self-esteem. For example, Nicole told me how the inability to quit psychotropic medication felt as failing to be strong enough to control herself independently from pharmaceuticals. Or Anna, for example, talked about guilt towards the fetus after a loss of bodily control due to psychotic illness symptoms. Attached to the ideology of self-control is a discourse of blame for those who fail to control their bodies. In what follows, I will show how the ‘liberating’ notion of control can stigmatize mentally ill women who lack self-control, or are perceived to lack self-control, by labelling them as dangerous and deviant.
4.2 Discourse of risk: risky and dangerous mothers.
“I find it quite selfish to have a child when you are psychologically unstable. Borderline and paranoid personality disorder…those diagnoses I find do not lend themselves for becoming a mother”.6 (Forum post)
It quickly became evident to me that there is a considerable stigma attached to pregnancy in women with a MD. Telling about my research topic at birthday parties, at my nursing job on a psychiatric ward or chatting about it with strangers, I often heard people saying “Well, that’s a heavy topic … those women actually should not get pregnant, right?”. These reactions reflect a strong public belief of psychiatric diagnoses as not fitting ideals of motherhood.
6
Original quote: “Ik vind het nogal egoïstisch om een kind te krijgen als je psychisch onstabiel bent. Borderline en paranoïde persoonlijkheidsstoornis…. dat vind ik geen diagnoses om moeder mee te worden.”
